Intercostal artery hemorrhage with hemothorax following combined lateral and posterior lumbar interbody fusion: a case report

INTRODUCTION: Lateral lumbar interbody fusion (LLIF) is a safe treatment for degenerative spine conditions. However, risk of complications such as vascular injuries remains. We report a unique case of an intercostal artery (ICA) hemorrhage with hemothorax following LLIF. CASE PRESENTATION: One hour after a right-sided LLIF L3-4 with posterior decompression L2-4 and L3-5 instrumentation, the patient became hypotensive, anemic and required vasopressor support. Evaluation revealed a right-sided hemothorax, which was caused by a bleeding intercostal artery, laterally at the 10th intercostal space. A lateral thoracotomy was performed to stop the bleeding. After vessel ligation and placement of two chest tubes, the patients’ hemodynamics improved. The patient remained intubated overnight and was extubated on the first postoperative day. DISCUSSION: Vascular injury is a rare complication of LLIF procedures. Most vascular injuries are segmental vessel lacerations, which resolve postoperatively. This is the first case description of ICA bleeding associated with LLIF surgery. Spontaneous ICA bleeding exists, but surgeons should be aware of careful handling in patients with vascular risk factors, especially with regard to patient positioning required in certain spinal surgical approaches. Timely vascular injury identification is critical for hemostasis and clinical management.